The Other Patient

Christo Joannidis

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I am accustoming myself to the idea of regarding every sexual act as a process in which four persons are involved.

Freud, 1899

The photograph of the fountain of truth may well be, but it is the fountain after it has been muddied by the photographer and his apparatus.

Bion, 1962

This paper addresses an often acknowledged and equally often overlooked aspect of the psychoanalytic encounter. It is not uncommon to hear comments about how differently, individual analysts respond to the same material, of the importance of the "match" between analyst and analysand, or of the so called "degree of unresolved pathology in the analyst". The implied point of reference in these statements is, it seems, an idealised condition that the analyst should be striving for, i.e. a state of being neutral, "tabula rasa", mirror like. There is no hesitance in recognising the frequent falling short of this imperative but the instruction to persist striving for it, remains it seems, impervious to this reality.It is the aim of the paper to claim that the notion of an analyst striving for neutrality is epistemologically untenable and that the more the participation aspect of the participant observer is underestimated or looked at for the sole purpose of taking it out of the equation, the more it will be driven underground and be given free rein in the realm of the unconscious. Ideals of abstinence and objectivity may end up promoting what is no more than an illusion which then runs the risk of encouraging tunnel vision. Paraphrasing the well known systems theory dictum that says "one cannot not communicate",it is essential that one recognises the fact that the analyst's personal presence cannot but affect and influence both the analysand and the process. Consequently, the subject matter of any analysis is not exclusively the analysand's unconscious or psychic constitution, the analysand's projections and other defence mechanisms, the analysand's trauma and distress or the analysand's developmental arrest but the relating that gets engendered in the room. Whereas the long term aim of an analysis in the form of a search for the analysand's inner truth remains unaltered, the subject matter of the day to day focus must needs be the understanding of the here and now encounter, under very special circumstances of two subjects one of whom has deliberately and consciously chosen to "wear a mask" (Kennedy, 1998) and an other who has consciously at least, accepted that this will be the case. Just as we now recognise that internal objects or internal representations are not simply internalised distortions of parental figures but internalisations of structures of relating that by now act as procedural templates outside the realm of subjective experience (Sandler, 1998), so too, the focus of analysis is not the internal world of one, but what gets created through the interaction of the internal worlds of two (Ogden, 1994).

Theoretical Background

In 1915 Freud talks about a communication that takes place between the patient's and the analyst's unconscious in the realm outside awareness. It is a clear acknowledgement of the fact that the analyst is unconsciously communicating to the analysand as well the reverse. How else could it be? It would be a betrayal of our very own theory, if we were to claim that the analyst who only a few months or years ago as an analysand himself was transferring, making full use of unconscious defence mechanisms, was employing projective identification etc. would somehow cease to do that, the moment he switches from using a couch to using a chair. Reality must surely be closer to Searles'(1978) courageous remark that one's own analysis does not decrease the gamut of emotions, but enables them instead, to come into a better harmony, a better balance so that no single emotional attitude predominates over the others. Sandler (1976a) is "...convinced that unconscious communication of the latent content of thoughts, wishes and fantasies goes on continually..." from analyst to patient just as much as the reverse. Whereas Bollas (2000), Lichtenstein and a variety of French authors, frequently refer to the realisation that in the interaction that stands as our model paradigm, the effect of the maternal unconscious upon the infant's psychic life is profound. The propensity, and indeed ability, analysands have to read the unconscious of the analyst and to monitor variations that reveal aspects of the analyst he may not be aware of himself, raises three fundamental issues that we can no longer afford to evade :

a)The fallacy of the impenetrability of the mask:

The analyst is constantly revealing himself. Commencing from simple overt characteristics like his appearance, his voice and use of language, his social skills, the aesthetics of his space and other inevitable choices he has made etc., all the way to more subtle indicators like: at which point he chooses to interpret (Renik, 1993), what he selects to interpret, in the transference or outside it, what conceptual model he employs, how consistently does he adhere to it, and if he shifts, when he does so, are all highly significant (Klauber,1986). They are also in full deployment for the analysand to observe and incorporate into his experience of who this person he is having an analysis with, is. Sandler (1976b) describes the analyst's free floating behavioural responsiveness as acting under motivational forces that may not yet be cognitively understood by the analyst. The long tradition of analyst centred interpretative mode (Langs, 1978, Casement, 1985, Bollas,1987, Steiner, 1993) has repeatedly highlighted the delicate balance that needs to be maintained between blatant revelation and enactment, which is undoubtedly an impingement, versus a tantalising double bind which may result in undermining the analysand's confidence in the reliability of his own emotional reactions and perceptions. It may also affect the trust in the analyst's truthfulness (Little, 1951), and foster fragmentation due to the rapid alternating of stimulation and frustration that destabilises the sense of reality (Searles, 1978).When one makes the interpretation :"You feel you are with an object who has such and such emotions in response to your doing such and such ...", one should be prepared for the hypothetical (or occasionally very real ) response from the analysand : "Well, are you having these emotions?" Alternatively the atmosphere remains laden with the feeling that there are things one can't know or can't talk about (Little, 1951). An analyst who harbours secrets, says Kennedy invites the analysand to have secrets from the analyst and thus develop split-off enclaves of phantasy. Anna Freud's classic definition of neutrality as the ability to maintain equidistance from the ego, the id and the superego, has often been misinterpreted as referring solely to the analysand. It was as early as 1957 that Racker made the following statement : "The truth is that [the analytic situation] is an interaction between two personalities, in both of which the ego is under pressure from the id, the superego, and the external world; each personality has its internal and external dependencies, anxieties and pathological defences ... and each of these[two] personalities respond to every event of the analytic situation"(p.132). It may be important at this point, to consider that it is equally vital for the analyst to maintain equidistance from his own three psychic structures. To fail to maintain this equidistance, claiming that the analyst's conscious comments and conscious perceptions of reality is all there is (Hoffman, 1983), and to hold an attitude that assumes the analyst's conscious reality is the norm against which the analysand's reality has to be compared and modified (Parsons, 1986) is to veer heavily on the side of the ego and betray the equidistance. When Renik (1993) talks about the self idealisation of the analyst that results from the belief in the possibility of the analyst transcending his subjectivity, I suspect that he is referring to the failure to maintain this vital equidistance. This failure may lead to coercion and as Brenman Pick (1985), has pointed out "when the split-off emotionality of the analyst returns, it will do so with all the risks of acting out". To imagine that the split-off emotionality won't return, she emphasises, is contrary to the very theories we hold in relation to mental life. A crucial element of the psychoanalytic encounter is the experience of being understood/recognised by another (or the lack of it). Given that a purely intellectual understanding is neither possible nor desirable nor indeed has any meaning, it is the affective impact that one concentrates on i.e. how the analysand affects the person of the analyst. Whether one uses the container-contained model (Bion), the survival of the object model (Winnicott) , the role-responsivenesss model (Sandler) or the classical model, the core issue of the impact of the presence of the analysand on the analyst and his response to that impact, remains indelible. Searles (1978) calls the need to force the analyst to admit that the analysand is having an emotional effect on him, the "source of one's strongest resistance". An analyst who does not permit his own subjectivity to be recognised, is one who offers to be experienced as an object rather than a subject. (Benjamin, 1988). Such skewed relating cannot but have consequences. From a non-psychoanalytic point of view, the encounter between two persons is conceptualised as requiring the mutuality of a desire to recognise and be recognised. The corresponding reference in psychoanalytic writings could be Freud's references to the fear of the loss of the object's love and how instrumental that is in the formation of relating activity. One would assume that it applies to both analysand and analyst.

The patient's perception of the analyst (i.e. the transference) not as a distortion in quality but as a distortion in degree :

The way the analyst is experienced by the analysand is in the realm of the transference. We have it on the highest authority (Freud) however, that the analysand uses attributes of the analyst as pegs to hang his own distortions/internal phantasies as transferential elements on. It is proverbially difficult to separate between what belongs to the analyst and what to the patient (Bollas, 1987) and since many theoreticians have advocated the view that the analysand's perception of the analyst is to be treated technically the same, irrespective of whether it is veridical or transferential (Hinshelwood, 1985, Steiner,1993), this ambiguity and paradox will forever form part of the conceptualisation. It is a short step but pivotal, from this fluidity to the attribution of the total situation to the analysand's initiative, albeit unconscious, and to disown the analyst's contribution. There exist two possible positions to take : one that stays with the uncertainty and the other that takes the short step towards certainty. This latter position sees the analysand as the instigator of the emotional atmosphere in the analytic process, and the analyst as the sensitive recipient of the communications (and/or projections) who then responds either in the grip of the transference (countertransference enactment) or analytically even if after a long period of "not knowing". If on the other hand one chooses the uncertain position that does not attribute the emerging matrix solely to the analysand's doing, then one is left with a much more complex and unnerving set up. This set up would of necessity expand our definition of the psychoanalytic encounter to incorporate the bi-directionality of the above described dynamic. Together with a) the analysand as instigator and the analyst as respondent , one would have to consider b) the analyst as instigator and the analysand as respondent, and the subject matter of the analysis would then be the recognition and interpretation of the intermingling of these concurrent dimensions. Tarachow (1962) makes a similar point when he underscores "the basic urge both patient and therapist have to mutual acting out". Parsons (1986) describes it as the patient's answer to what matters to the analyst, while Little (1951)talks of the patient holding a mirror to the analyst. Renik (1993)on the other hand provocatively claims that everything the analyst does is based on his own psychology which, he says, is a limitation that cannot be reduced, let alone be done away with. He also quotes Lacan and his conceptualisation of the analyst as "le sujet supposé savoir" , which attempts to draw attention to the inevitability of some degree of suggestion in any analysis and to its consequences. Hoffman (1991) reminds us of the idea, first put forward by Loewald (1986), that there are just as good reasons for calling the patient's experience countertransference in order to emphasise the responsivity to the analyst, as there are to call the analyst's experience transference, in order to emphasise the extent to which he is the initiator of interactional sequences. Other theorists would see the patient acting as a therapist to the analyst (Searles, 1978), responding to the analyst's subjectivity (Aron, 1991), or monitoring the analyst's countertransference, and the free associations being no more than commentaries on that (Langs, 1978).

c)The essence of what is being communicated by the analyst i.e. the analyst's needs, be they instinctual or defensive :

The issue of the person of the analyst is enormous and there is no way an article like this could do justice to the complexity it entails. In an attempt to address the issue of the analyst's conscious and unconscious motivation, his conscious and unconscious needs and defences as well as how they inevitably and mostly unconsciously affect the process of psychoanalysis, I will simply confine myself to a brief and incomplete survey of some of the insights presented by different theoreticians :

It is noted that there is a tendency to avoid transference interpretations - a counter-resistance to making them - because such interventions draw the full impact of the analysand's libido onto the analyst and thus put the analyst's relationship to his own unconscious impulses to test. It is also noted that the reluctance to interprete the transference may be influenced by a wish in the analyst not to know (Strachey,1934, Racker, 1958, Klauber, 1986, Hinshelwood, 1985, Brenman Pick, 1985).Conversely the insistence on or exclusivity of transference interpretation may be indicative of feelings of grandiosity and self-importance (E. Jones ,1913) or narcissistic longings for idealisation - phantasies of having become the centre of the analysand's emotional life (Gabbard, 1995a).

Given that the analyst has his own object needs and given the continuous investment he makes on the analysand and the analytic process, the patient inevitably becomes a kind of love object for him. Fear of losing the object, fear of losing the object's love and having to deal with abandonment and loneliness may unconsciously promote the tendency to overcome this through the use of the analysand in some way and most particularly through fostering dependence (Tarachow, 1962, Little, 1951, Searles, 1978).

It is important to remember the fear of incompetence in the analyst, his fear of failure, fear of craziness, frustration of the sublimated instinctual forces etc., which may all subtly lead to the tendency to attribute phenomena to "transference projections" of the analysand and/or deny own anxieties through the use of interpretations (King, 1978, Szasz, 1963, Searles, 1978, Bion, 1963).The analyst's narcissistic vulnerability plus the necessity to always doubt and constantly question the validity of his understanding puts him in a position where, an analysand's criticism, contempt or devaluation may deeply wound him and provoke either a wish to counter-attack in an attempt to re-establish authority or a retreat to a stony withholding silence (Gabbard, 1995a). The analysand may, on the other hand, for his own reasons willingly collude and comply (Hinshelwood, 1985, Racker, 1958) because he clearly senses the analyst's unease (E.Balint, 1968).

There is mention of the ever-present sadomasochistic elements in the psychoanalytic process i.e. the interpretation as a depriving act that imposes separation and loss, the temptation to exercise control, be all knowing and expect that the analysand surrender his defences against painful ideas and feelings. The failure to gratify and the expectation to put up with non-gratification, also fall into that area of experience. (Tarachow, 1962, Garner, 1961, Searles, 1978, Brenman Pick, 1985).

The principal temptation the analyst finds himself struggling with is to be parental, to play the role of mother or see the analysand as an early aspect of oneself (Tarachow, 1962, Money-Kyrle, 1956, Little, 1951, Brenman Pick, 1985).Just as prevalent is the conviction that through care and attention he will provide a better (and hence curative) experience to the analysand than the one his own parents did provide.

It is acknowledged that fear of collusion/seduction with the analysand or of being caught up in an "overvalued idea" may result in a reaction formation rigidity, which makes communication very problematic (Loewald, 1984, Boesky, 1990, Britton & Steiner, 1994).

Equally, idealisation of the analyst's ability to be objective can foster complacency and sow blind spots, i.e. failure to recognise that an interpretation is a kind of imposition of the analyst's own truth and is being heavily influenced by unconscious countertransference feelings. In other words, it is a form of behavioural enactment. Elements of coercion and suggestibility may end up being denied rather than examined. (Tarachow, 1962, Hoffman, 1983, Renik, 1993).

The analyst's own unconscious guilt for the harm done to his internal objects and the severity of his own superego plays undoubtedly a vital role (Money-Kyrle, 1956, Little, 1951, Brenman Pick, 1985, Searles 1966).

The analysand may be experienced as the internal damaged object of the analyst's unconscious phantasy and the object of his reparative drive. If this reparative drive is thwarted (i.e. incomprehension ), unconscious guilt and anxiety may increase, further limiting understanding. There is great temptation at this point to offer to the analysand love (reassurance) as an ostensible reaction formation or resort to hostility/dismissal, both of which are defences against the analyst's emerging depression (Money-Kyrle,1956, Little, 1951, E.Balint, 1968, Gabbard 1995).

Finally one can't disregard the fact that the analyst's need to preserve his own psychic equilibrium, at any given moment, will determine his response to the patient much more profoundly than any desire to understand and help him (Feldman, 1994).

All in all, the concern is around how the analyst may be prepared to deal with his own unconscious gratifications and limitations in view of the inevitable encounter during the psychoanalytic process, with his own frightening and unwanted feelings, especially when the analysand corresponds too closely to not understood aspects of one's own self. The analytic situation one should not forget, is a compromise formation for both a wish for intimacy and a defence against it for the analyst, thus providing a quasi-mastery of powerful affects brought on by close and direct relationships with other people (Greenson, 1967). Despite such complexity, which represents only a proportion of what happens in an analysis, the paradigm of uni-directionality has survived. There must be powerful forces that keep it afloat and it may be that we shall need to fully understand them first before we get a clearer and more systematic understanding of all the conscious and unconscious fields overlapping in the consulting room. No one could be more succinct than the non-analyst Vygotsky (1988) when he writes : "A true and complex understanding of another's thought becomes possible only when we discover its real, affective-volitional basis ... when we reveal the most secret internal plane of verbal thinking - its motivation" (p.282).

Philosophical Perspectives

In the field of philosophical enquiries, the meeting of two persons has a long and distinguished history, starting not surprisingly, in antiquity. The greek term for face/persona (πρόσωπον) literally means standing in front of the Other's eye, perhaps to signify that I can know myself only through the Other. Plato in his dialogue entitled "On the Nature of Man" , formulates it thus :

You have observed that the face

of the person who looks into an other's

eye, is shown in that eye confronting him

as in a mirror - it is the image of the

person looking.

And the soul too, my dear Alcibiadis, if

it is to know herself, she must surely look

at a soul.

[132-133]

Paul in the Corinthians [13] describes the supreme moment of meeting Godhead as "but then face to face.....shall I know even as also I am known".

For Hegel self-consciousness can only come about via another self - consciousness. In his famous master/slave paradigm, he states that to safeguard his life, the slave agrees to recognise the other as master. But the master can never be satisfied by the recognition of a slave because self consciousness can only achieve recognition in another fully independent consciousness i.e. the slave must also recognise his own mastery over the master. Self consciousness is dependent therefore upon the mutual recognition of consciousnesses and can only occur when two consciousnesses "recognise themselves as mutually recognising one another"(Kojeve, 1947). Self-consciousness seems to arise out of an intersubjective relationship. This intersubjective tradition informs the writings of Habermas, Buber etc. For Lacan as for Sartre or Levinas however, mutual recognition is unattainable since the Other introduces a "radical semantic uncertainty into language" and thus "any intersubjective engagement is barred"(Theunissen, 1977). For them the subject is inscribed with a lack of being that can never be overcome. The subject is viewed in terms of unfulfilled desire and any possibility of reciprocity is denied. The self and other remain irreconcilably divided and intersubjectivity is established upon the desire to dominate the other. Self-consciousness is defined as pre-reflective and non-relational, self-recognition is considered a mis-recognition, and the ego is characterised by alienation, lack and estrangement. Since the ego is decentred, any stable unifying identity can only be illusory. The existence of the other as subject, writes Sartre, can only manifest itself by reducing me to the state of an object. Levinas(1958)too takes issue with Buber and his I-Thou concept, and points out that the element of concern (fuersorge) and the corresponding indebtedness, necessary for the emergence of the I's independence, introduce separation and asymmetry and therefore the inevitable "alterity" into the proposed symmetrical I-Thou. Consequently the issue of recognising and being recognised forms a part of what he calls "the ethical relationship" which he defines as "a relation with an inassimilable and thus incomprehensible -foreign to knowledge and possession- alterity of the Other". Not dissimilar a notion one would think, to what Winnicott (1963) has called the "incommunicado" element. While Sartre, Lacan and Levinas represent one pole of the spectrum, the intersubjectivists like Buber, Habermas etc. stand at the other end. They would state that the encounter does not take place in each of the participants or in a neutral unity encompassing them but instead between them, i.e. "in a dimension accessible to them alone" hence in simultaneity rather than in sequence. Buber(1958) goes on to explain that in the beginning is the Relation i.e. one of the characteristics of the I-Thou is that it cannot be reduced to the terms related. Whenever the terms related are pre-eminent, the I-It already dominates !

Psychoanalysis needs to find its position on this spectrum. If the analysand is to be thought of as anything other than a specimen under observation and the analytic situation far beyond a re-enactment, the whole gamut of the above considerations must needs be taken into account. Pontalis (1977) regards the work of psychoanalysis to move the client "from a position of need to a position of desire, to become that is, an agent able to meet, to speak and love an Other". For this to happen, the analytic situation will have to be recognised for what it is i.e. a mutual (mutual but not symmetrical) regulation through constant affecting of one another, including the occasional inevitable breakdowns of communication (Kennedy,1998). Winnicott (1963) tries to integrate these two opposite positions in a paradox when he writes that although healthy persons enjoy communicating, in fact can't exist without it, the other fact is equally true that "each individual is an isolate, non communicating, permanently unknown, in fact unfound".

Psychobiological Perspectives

Psychobiological research has over the years studied mother-infant interactions extensively (Emde, 1988). It is a field of study of great relevance for the theory of psychotherapeutic processes and the therapist-patient dyad, because it has frequently been thought of as a kind of model/paradigm for it. The impressive findings and theoretical conceptualisations of what takes place in the former interaction are therefore of great heuristic value for the latter. Starting with the understanding of the vital significance of the right brain in humans - an area in the brain whose many functions correspond to processes traditionally attributed to the freudian Unconscious (Joseph 1992), Schore(1994) talks of attunement between two partners as representing synchronisation of two right brains. He mentions research that highlights the role of right brain to right brain affective communication at levels beneath awareness in both mother-infant and therapist-patient dyads. It is now well established that just as the left brain communicates its states to other left brains via conscious language use, so too the right brain, non -verbally communicates its unconscious states to other right brains that are tuned to receive these communications. Whereas neurobiologists can now confidently claim that mother's right brain is being used by the baby as a template to mediate its expanding affect regulating capacities (alpha function!!), they can also add that mother's right brain is equally being influenced by these relational transactions. As the mother and infant match each other's affective patterns, each recreates an inner psycho - physiological state similar to the partner's. As if proof were ever needed, research has established that the emotional availability of the caregiver inintimacy, is the most central growth promoting feature of early rearing experience (Emde, 1988). It is this subjective participation that is responsible for the reparation of the dyadic misattunements. Stern(1998) using a slightly different jargon, portrays how a "now moment" that is therapeutically seized and mutually recognised can become a "moment of meaning" (the potentially mutative element). This, he says, requires that each partner contribute something unique and authentic as an individual in response to a "now moment". This response must be created on the spot to fit the singularity of the situation and it must carry the therapist's signature and not be bound by technique or theory. It is a kind of enactment that needs to be mutually recognised and ratified for it to have reaching effect. The intersubjective nature of these processes could not have been stressed more emphatically.

Clinical Examples

The examples to be presented (all from different analysands) are inevitably tainted by virtue of the fact that I can describe only what enters my consciousness and accede to the ongoing presence of unconscious forces and phenomena involving me that lie beyond my awareness. My purpose is to evoke a sense of recognition of a barely graspable bi-directionality that is at play. Hence the material is deliberately left unelaborated :

Vignette I :

The analysand is foreign. The analysis is being conducted in a language that is the mother tongue of neither the analyst nor the analysand. There is no way that the analysand could consciously know that the analyst speaks her mother tongue and that that language has formed part of his own childhood experiences. The analysand often mentions words in her mother tongue and then struggles to translate them. She also gives detailed accounts of places, cultural peculiarities, mores etc. The analyst observes her struggles but is also aware of the things that are not being mentioned, significant nuances that are not being translated. The analyst is conscious of a degree of excitement in himself, resulting from his sense of voyeurism : knowing that she doesn't know that I know. This the analyst is conscious of, what else is there that the analyst is not conscious of.

Vignette II :

The session starts normally. Within 10-15 mins, the analyst starts feeling sick. He feels nauseous, has a tummy-ache and there is an urgency to leave the room. He has the thought that it must be the bug his family had been suffering from recently. He decides to continue. As the session proceeds however, he is getting progressively worse so that with twenty minutes to go, he is so preoccupied with his own condition that he realises he is unable to think. He wonders whether to stop the session or not, but chooses to continue to the end. He says nothing to the analysand. The next session the analysand reports that the last time she had felt "awful". She can't specify what it was, but she felt that the session had been "terrible". She had left the room feeling extremely "upset and alone, without quite knowing why!" The analysand had had an "urge to attack my body, afterwards!"

Vignette III :

The analysand complains that he doesn't know me, isn't privy to my thoughts, is not being helped to understand what makes me say the things I say etc. After a long stretch of incessant complaint I say that I think he may be angry that I'm not giving him what he wants and that I stick to my role as his analyst. He responds by saying :

"Don't you dare tell me that I'm angry, you can only tell me if you are angry, not what I am supposed to be feeling."

There follows a long pause. He then resumes :

"What does it feel like to be told what you are supposed to be like?"

Another long pause. He asks :

"Why won't you answer ? Is this what they call being a responsive therapist ?"

There is another long pause and the session ends. I am left with thoughts. The analysand may be attacking the analyst and/or the process, the analysand may be being concrete in his thinking and unable to appreciate the "as if" quality of analysis. May be there is no therapeutic alliance, may be this is a significant total transference situation of which my countertransference forms a part. Whatever it is, the analysand is certainly in a place inaccessible to analytic work. I am left feeling that I am somehow teasing and depriving someone who is getting progressively more anxious. I am also aware that I have (defensively?) shut up and avoided saying anything the rest of the session. Can one. in all honesty, think of the mood in the room as the exclusive creation of the analysand ?

Vignette IV :

The session with a professional dancer starts with twenty minutes silence.

A/and : When I am talking about myself it is clear. When I am talking about the weather, could I not be talking about myself too?

Long pause.

Why don't you answer? I think I could be talking about me, only not know it. I mean weather, hot, cold, clouds, it could mean anything, depending on what you focus on.

Long pause.

Aren't you going to answer me? I said when I talk about the weather, couldn't I be talking about me as well - symbolically I mean ? Only you would have to work hard to understand it.

A/yst : You have an image of me thinking about you. Working very hard trying to understand why you might be being indirect rather than being straight.

A/and : Straight? Why, am I not allowed to be curved, then?

Long pause.

A/yst : Curved?

A/and : Well, you probably don't know this but in choreographic language, a movement line can either be straight or be curved. So that's what came to my mind, that's my free association....... Are you implying that in this analysis one is forbidden to be curved?

Long pause and it's the end of the session.I am puzzled. Is this flirtatiousness and teasing, is it mockery, is it concrete psychotic thinking or an example of Bion's reversible perspective? It feels as if there is no therapeutic alliance and one is therefore communicating past each other. I try to make sense through the mood and I'm still left feeling confused and deskilled. I have been here before, with this patient and my eagerness and curiosity are rapidly reaching their limits. This is not "not knowing" that leads to discovery, it feels more like not knowing that will lead to spiraling despair. I know I can't pretend to understand and I am also aware that when in the past I made my incomprehension known, I was simply shoving my disappointment into the patient. I feel stuck, supervision and consultation feel stuck and I am starting to think of ways to extricate myself. I don't for a moment imagine that my frame of mind is not affecting and reinforcing the impasse in the room.

Vignette V :

After a transference interpretation there follows a long silence. I comment on the silence and get this response :

I guess one reason I stopped talking is that quite often when I talk about things that concern me, you almost always bring it back to my presumed difficulties with psychoanalysis, trying to figure out what thoughts I have about you etc. I just don't want to think like that, because if it ever seems relevant to me I ought to know it before you do.

It could be that my interpretation was maladroit, that the timing was wrong, or that it was indeed a transference enactment I got caught up in. But one can't but be wary of the subtle element of coercion that is being hinted at.

Vignette VI :

For a period of months, the analysand avoids looking at me as she enters the consulting room. Her whole body including her head is turned away, her gaze is averted and she lets her hair fall over her face. Consistently. I try to make sense, I make the occasional comment, all to no avail. One day I say that may be she is afraid that were I to see her face and meet her gaze, I might be turned into stone like Perseus meeting the Medusa. The moment I say it I regret having said it. I start thinking that it was an unsolicited interference on my part, an association I had had myself, which might even have an element of teasing. The analysand may not have even heard of the myth I am alluding to but even if she has, how might she take it?

My comment is followed by a long silence and the analysis moves on. Years later the analysand recalls the incident and describes it as a pivotal point in her analysis. She says that at that moment she had felt respected by me in that I was revealing something about myself.

"Instead of leaving me to struggle on my own you were participating by dirtying you hands as well", she said.

In retrospect one could think of this as a countertransference enactment engendered through projective identification, with the analysand locating disowned aspects of herself into me.

Nevertheless, I can't avoid thinking that if it hadn't been for my subjectivity acting almost against my conscious better judgement, it would never had become the "moment of meaning" the analysand experienced it as.

Concluding Remarks

It is not easy to extrapolate from these clinical vignettes. They are fragments out of

context and as such amenable to many and varied interpretations and

re-constructions. Starting from the position that the bi-directional communication

from unconscious to unconscious is delimited in its expression to the area outside

conscious discourse (Nacht, 1964), one is made aware of the fact that attempts at

further rational elaboration and theoretical formulation of the clinical material,

however tempting, run the risk of missing the point one is trying to bring into focus,

i.e. that one can only get a whiff, no more. It is inevitable therefore that each reader

of this paper will get involved in his own very personal meaning-giving process and

the conscious and unconscious tools he will be employing will derive from his own

subjectivity. I am presenting them as instances where I have become conscious of

my contributions to the process that I had been observing. With that came the

realisation that elements beyond my awareness must surely be contributing as well,

irrespective of whether the analysand is conscious of them or not. Analysis as a

whole is of course, a process and not a point in time, it is a long-term encounter with

a context, a continuity and a development that is convoluted and multi-level, but still

not that dissimilar in many ways to what happens in these vignettes. There may be

very little that is objective in this unfolding spiral of thesis - antithesis - synthesis

that informs psychoanalysis. How the school of psychoanalysis the analyst adheres

to, influences his understanding and conceptualisation of the material as well as his

mode of interpreting and conducting the analysis, is only one minor and often

conscious and shared piece of evidence for this.

The analysand's "material" is as much a rorschah inkblot for the analyst in his

struggle with meaning-giving as the analyst's presence and words are for the

analysand. One is involved in a process of a cumulative nature, and which evolves

through the reciprocity entailed in the progression of moments of contact of ever

increasing complexity.

In his attempts to tackle the issue of subjectivity in the psychoanalytic situation,

Bollas (1987) encourages the analyst to think of himself as "the other patient" , and

goes on to say that the "the clinician must find a way to make his subjective states

of mind available to the patient and to himself.......even when he doesn't know what

these states mean"(p.203). This borders on the controversial debate on disclosure

that has plagued psychoanalysis since Ferenczi's experiments. Lots has been written

on this issue, but it may in the end turn out to be a pseudo-dilemma, in that as

far as the essential core is concerned, the analysand already knows. The analysand is

constantly taking in consciously or unconsciously definite perceptions regarding the

analyst as a real person, overall and at any given moment. Just as the analyst often

listens to the mood beyond the words, so too we have to concede, does the analysand

(Brenman Pick, 1985). How that is then elaborated within the total transference

situation is an inevitable second step and may belong mainly to the patient.

The dilemma of disclosure is a direct consequence of the epistemologically

untenable notion - derived from Bion's frequently misapprehended comment about

working "without memory or desire" - that the pursuit of truth ( K ) can be engaged

in without concurrent L or H. It remains a very prevalent premise even though it

has repeatedly been refuted over the years. Simply put, does being a neutral analyst

mean that he or she is cold and with no feelings (Segal,1978)? If disclosure is then

not the issue, the task one is left with, will be the prevention of possible undue

impingement onto a situation that is mutually created by two subjects in the common

pursuit of truth. The shift of focus from the analysand's internal world and its

realisation in the analytic space, to the interaction between two subjects (mutual but

not symmetrical) that has been so elegantly portrayed by Thomas Ogden as "the

analytic third", invites a re-conceptualisation of our day to day understanding of

what happens in an analysis.

The familiar image of the figure/ground employed by some psychoanalytic authors

(Benjamin, 1988, Hoffman,1983, Bion,1961) to describe the analytic situation, does

indeed convey quite convincingly the live paradox of the bi-directionality entailed in

any analysis. Failing to see that the analysand transfers the preconception onto or

into parts of the analyst that permit or at times promote this mating in order for the

transference realisation to be established, is tantamount to advocating that the

attributes of the container can be disregarded when examining the containment

process. If this is inconceivable for the mother-baby dyad, it is equally inconceivable

for the analytic dyad. Our complex concept of countertransference has sometimes

been thought of in what appears like defensive ways. Initially it was defined as

something to be avoided or to be grown out of because it comes from the analyst.

The last few decades however it is understood as something valuable because

inevitable and to be made use of. Peculiarly though, theory has gone to the other

extreme, and now countertransference is frequently misunderstood as a state evoked

in us exclusively by the analysand (so it is a communication by the analysand about

his/her internal world) and saying nothing about us as agents who have their own

unconscious world permeating subliminally the conscious countertransferential

thoughts and feelings. Baranger (1993) has no doubts when she makes the point that

the transference/countertransference manifestations spring from a basic unconscious

phantasy, which phantasy, as a creation of the "field", is rooted in the unconscious

of each of the participants.

It seems to me that as philosophical and infant research theories converge in their

understanding of the human encounter, psychoanalysis with its unique focus on

unconscious processes, cannot but tend toward this point of convergence and

redefine its field of vision as that very particular and certainly asymmetrical area of

overlap of two unconscious systems in a common conscious pursuit. The study of

this phenomenon - which is the subject matter of analysis- cannot but be the study of

the meeting of the two individual systems and not the vicissitudes of only one. This

latter view seems to claim that the one unconscious system overwhelms the analytic

situation totally and that the analyst's unconscious has already reached

consciousness and is therefore not truly present in the interaction. Can such a view

be defensible still ?

It will undoubtedly be pointed out that these are anxieties of a recently qualified

analyst. It is true, of course. One can only hope that the years to come will not dull

these concerns.

A B S T R A C T

This paper argues for the widening of perspective in the understanding of the

functioning of the analytic process. By focusing on the complementary half of the

bi-directional communication from one unconscious to another - the half that

remains outside the analyst's conscious understanding or experience - it advocates

that the conceptualisation of the work we do, can be enriched without recourse to

changes in technique. Refusing to lose sight of the fact that the analyst's

unconscious is, unbeknownst to him, constantly conveying messages to the

analysand who then responds in accordance to these communications , can only

deepen our appreciation of the analysand's internal world and of the process of

analysis.

A selection of writings by psychoanalytic, philosophical and infant psychology

authors as well as clinical material is enlisted to support the argument.

Word count : 7500

R E F E R E N C E S

Aron, L.(1991). The patient's experience of the analyst's subjectivity. Psychoanalytic

Dialogues, 1: 29-51.

Balint, E. (1968). The mirror and the receiver. In Before I was I, ed. J. Mitchell &

M. Parsons. London: FA Books,1993, pp.56-62.

Baranger, M. (1993). The mind of the analyst. International Journal of Psychoanalysis,

74: 15-24.

Benjamin, J.(1988). The Bonds of Love. London: Virago.

Bion, W. (1961). Experiences in Groups. London: Tavistock.

_______. (1962). Learning from Experience. London: Maresfield.

_______. (1963). Elements of Psychoanalysis. London: Maresfield

Boesky, D.(1990). The psychoanalytic process and its components.

Psychoanalytic Quarterly, 59: 550-584.

Bollas, C.(1987). The Shadow of the Object. London: FA Books.

Bollas, C.(2000). Hysteria. London: Routledge

Brenman Pick, I.(1985). Working through in the countertransference. International

Journal of Psychoanalysis, 66: 157-166.

Britton, R.& Steiner, J.(1994). Interpretation: selected fact or overvalued idea.

International Journal of Psychoanalysis, 75: 1069-1078.

Buber, M.(1958). I and Thou. Edinburgh: T. & T. Clark.

Casement, P.(1985). On Learning from the Patient. London: Tavistock.

Emde, R.(1988). Development terminable & interminable. International Journal of

Psychoanalysis, 69: 23-42 & 283-296.

Feldman, M. (1994). Projective identification in phantasy and enactment.

Psychoanalytic Inquiry, 14: 423-440

Gabbard, G.(1995). When the patient is a therapist. Psychoanalytic Review,

82: 709-725.

Gabbard, G. & Lester, E.(1995). Boundaries & Boundary Violations in

Psychoanalysis. New York: Basic Books.

Garner, H.H.(1961). Passivity and activity in psychotherapy. Archives of General

Psychiatry, 5: 411-417.

Greenson, R.(1967). The Technique & Practice of Psychoanalysis. New York:

Int. Univ. Press.

Hinshelwood, R.(1985). The patient's defensive analyst. British Journal of

Psychotherapy, 2: 30-41.

Hoffman, I.(1983). The Patient as interpreter of the analyst's experience.

Contemporary Psychoanalysis, 19: 389-422.

______.(1991). Toward a social-constructivist view of the psychoanalytic

situation. Psychoanalytic Dialogues, 1: 74-105.

______.(1994). Dialectic thinking and therapeutic action in the psychoanalytic

process. Psychoanalytic Quarterly, 63: 187-218.

Jones, E.(1913). The God Complex. In Essays in Applied Psychoanalysis, Vol. II,

London: Hogarth Press,1951, pp. 244-265.

Joseph, R.(1992). The Right Brain and the Unconscious. New York: Plenum Press.

Kennedy, R.(1998). The Elusive Human Subject. London: FA Books.

King, P.(1978). Affective response of the analyst to the patient's communication.

International Journal of Psychoanalysis, 59: 329-334.

Klauber, J.(1986). Difficulties in the Analytic Encounter. London: FA Books.

Kojéve, A.(1947). Introduction à la Lecture de Hegel. Paris: Gallimard.

Langs, R.(1978). Technique in Transition. New York: Jason Aronson.

Levinas, E.(1958). Martin Buber and the Theory of Knowledge. In The Levinas

Reader, ed. S. Hand. Oxford: Blackwell, 1989, pp.59-74.

Lichtenstein, H.(1977). The Dilemma of Human Identity. New York: Jason Aronson

Little, M.(1951). Counter-transference and the patient's response to it. International

Journal of Psychoanalysis, 32: 32-40.

Loewald, H.(1986). Transference-countertransference. Journal of the American

Psychoanalytic Association, 34: 275-287.

Money-Kyrle, R.(1956). Normal counter-transference and some of its

deviations. International Journal of Psychoanalysis, 37: 360-366.

Nacht, S.(1964). Silence as an integrative factor. International Journal of

Psychoanalysis, 45: 299-303.

Ogden, T.(1994). Subjects of Analysis. London: Karnac Books

Parsons, M.(1986). Suddenly finding it really matters. International Journal of

Psychoanalysis, 67: 475-88.

Pontalis, J.B.(1977). Entre la Rêve et la douleur. Paris: Gallimard.

Racker, H.(1958). Counterresistance and interpretation. Journal of the American

Psychoanalytic Association, 6: 215-221.

Renik, O.(1993). Analytic interaction: conceptualizing technique in light of the

analyst's irreducible subjectivity. Psychoanalytic Quarterly, 62: 553-571.

Sandler, J.(1976a). Dreams, unconscious fantasies and 'identity of perception'.

International Review of Psychoanalysis, 3: 33-42.

_____.(1976b). Countertransference and role-responsiveness. International Review

of Psychoanalysis, 3: 43-47.

_____.(1998). Internal Objects Revisited. London: Karnac Books.

Searles, H.(1966). Feelings of guilt in the psychoanalyst. Psychiatry, 29:319-323.

_____.(1978). Concerning transference and countertransference. International Journal

of Psychoanalytic Psychotherapy, 7: 165-88.

Segal, H.(1978). Countertransference. International Journal of Psychoanalytic

Psychotherapy, 6:31-37.

Schore, A.(1994).Affect Regulation and the Origin of Self. Hillsdale, NJ:Erlbaum.

Steiner, J.(1993). Problems of Psychoanalytic Technique: Patient-centred and

Analyst-centred Interpretations. In Psychic Retreats. London: Routledge.pp.131-146

Stern, D.(1998). The process of therapeutic change involving implicit knowledge.

Infant Mental Health Journal, 19: 300-308.

Strachey, J.(1934). The nature of therapeutic action in psychoanalysis. International

Journal of Psychoanalysis, 15: 127-159.

Szasz, T.(1963). The concept of transference. International Journal of

Psychoanalysis, 44: 432-443.

Tarachow, S.(1962). Interpretation and reality in psychotherapy. International Journal

of Psychoanalysis, 43: 377-387.

Theunissen, M.(1977). Der Andere : Studien zur Sozialontologie der Gegenwart.

Berlin : Walter de Gruyter & Co.

Vygotsky, L. (1988). Thinking and Speaking. In Collected Works of

L. S. Vygotsky. vol. I, ed. R.W.Rieber & A.S.Carton. New York : Plenum Press

Winnicott, D.(1963). Communicating and not Communicating Leading to a

Study of Certain Opposites. In The Maturational Processes and the Facilitating

Environment. London: Hogarth Press,1985, pp.179-192.